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A 52-year old woman with type 2 diabetes complains of low back pain that began after rearranging the furniture in her house one week ago. She says the pain is constant, and shoots down her right leg. It’s worse when she sits and tries to get up. The pain level varies from 5-7/10 and is only partially relieved by acetaminophen and ibuprofen. She got more relief from a couple “leftover codeine pills” from a dental procedure she had two months ago.

Your patient returns, stating that her low back pain has mostly resolved with ibuprofen and the back stretching exercises you gave her. She also reports that she has found a new job and is very happy about that.

However, this episode has made her more aware of some longstanding tingling, burning pain in her right foot, and it’s worse over the last six months. She’s now noticing symptoms on the left, too.

You continue to work through a number of pain treatments for your patient’s peripheral neuropathy over the next year – high doses of anticonvulsants were minimally effective for her. Topical lidocaine patch helped somewhat, but were too expensive. She finally found relief in a combination of amitriptyline 25mg at night, which helps her sleep, and using biofeedback exercises she learned at a multidisciplinary pain clinic you referred her to. She now has pain of 3/10 on most days, which she says she can handle.

A 46 year old patient of yours has experienced a motor vehicle accident last year which shattered his left knee. He has had multiple unsuccessful knee surgeries at which have failed to relieve his pain. His pain is 8/10 on most days, but his orthopedic surgeon refused to give him opioids for fear of causing addiction. The patient has a past history of injection drug use in his 20’s. The patient comes to you and asks if you can give him the “strong stuff” he really needs.

Your patient has followed his pain contract and seen you monthly since starting methadone 20 mg po bid. He uses approximately 30 vicodin tablets a month for breakthrough pain. A daily combination of senna and colace controls his symptoms of constipation. He has kept his appointments and random UDT on two occasions was consistent with taking methadone as expected. His pain is now 4-5/10 on most days and he’s still considering more surgery, but he is able to walk more and credits you for believing him and restoring hope that he can continue to get better.

A hospitalized 72 year old woman with metastatic breast cancer is scheduled to go to home hospice tomorrow. An alert nurse informs you that the patient continues to report back pain of 8/10 from her bony metastases despite current therapy with fentanyl patch at 50ug/hr. Her family asks you not to give drugs that will be “too sedating”.

You had a team meeting with the patient and her family, including your social worker, hospice personnel, oncologist, and in-house pain management team. You kept her in the hospital for an extra couple days to initiate high dose steroids and palliative radiation. This helped at first, but when the pain returned, she decided to forego additional radiation treatments. She required escalating doses of morphine from her family and hospice workers for her pain. Her husband calls to tell you she died, and to thank you for your support through this process.